- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,118.22 / $3,118.22 / $3,118.22
| Professional | | $3,118.22 | $3,118.22 | $3,118.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,075.00 / $7,978.00 / $9,574.00
| Professional | | $7,075.00 | $7,978.00 | $9,574.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,473.46 / $4,445.10 / $7,492.51
| Professional | | $3,473.46 | $4,445.10 | $7,492.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,878.60 / $9,167.60 / $12,744.60
| Professional | | $3,878.60 | $9,167.60 | $12,744.60 |